2018 Nicholas E. Davies Enterprise
Award of Excellence
William Holland, MD, VP Care Management, CMIO
Michael Simons, MD, Medical Director, Virtual Care
Banner at a Glance
Our Mission:
Making healthcare easier,
so life can be better.
Our Strategy:
• Integrated governing process
– Single Board of Directors
– Centralized management structure
– Centralized corporate functions
• Designed to achieve results
– Enhance clinical quality
– Affordable cost model
– Patient/member experience
• Alignment from strategy through initiatives
– Drives common strategy from senior leaders down through entire organization
– Allows IT leaders to tightly align technology strategies with Banner strategy
– Aligns IT sub-strategies and tactics across IT operations
Banner’s
Operating
Model
The Banner Operating Model
Clinical Reliability at Banner
•Banner’s approach to quality and safety is based on ensuring
reliability* of its clinical systems and processes including:
*The capability of a process, procedure or health service to perform its intended
function in the required time under existing conditions. (IHI, 2004)
Defining clinical standards,
designing delivery processes,
and implementing across the
organization
Identifying and
addressing opportunities
for further improvement
Monitoring and assessing
performance to those
standards and addressing
periodic issues
Clinical Consensus Groups (CCG)
ED
Pulmonary
Palliative Care
NICU/Newborn
Neurosciences
Critical Care
Behavioral Health
Anesthesia
Pediatrics
Women’s Health
Post Acute Care
Medical Imaging
Primary Care
Hospital Medicine
Cardiology
Urgent Care
Surgery
Pharmacy &
Therapeutics
Infectious Disease
CV Surgery
Oncology
Ortho
Clinical
Leadership
Team
Program
management
CCGs and
Clinical
Practice
Development
Informatics
Clinical &
Medical
Professionals
assist with
design & build
Quality
CPA
Clinical
Performance
Analytics
Clinical
Education
Process
Engineering
Clinicians and
Engineers assist
with Design
Purpose: Define expected clinical practices for Banner Health based on best available
evidence, including practice- based evidence.
“Engineering” New Models
DDI Process for Implementing Evidence Based Clinical Practices
• Research
Practices
• Reach Consensus
on requirements
Define
• Describe reliable
workflow and
roles
• Develop tools
Design
• Communicate
and train
• Address issues
• Monitor
Implement
Virtual Care
Increasing Capacity to Deliver Highly Reliable Care
Local Problem
How does Banner Health improve outcomes by
providing highly reliable care while increasing
capacity to deliver care?
Virtual Visits Will be the
Primary, Preferred Access
Points for Routine, Low-
Acuity Care
94% Resolution rate for virtual
visits – no follow-up care needed
after visit.
By 2029, when the last round of
boomers reaches retirement age, the
number of Americans 65 or older will
climb to more than
71 million
up from about 41 million in 2011
according to Census Bureau estimates.
73%
increase
IOM report suggests that, in the United States, one-third of
all hospital patients experience harm during their stay and,
each year, more than 400,000 preventable hospital deaths
occur..
Mortality rates in ICU
average 10-20% Overall, over
200,000 patients die in US ICUs each
year. Given the high stakes involved,
the quality of care delivered in ICUs
is particularly important.
Unfortunately, evidence suggests
that quality varies widely across
hospitals.
Physician Shortages in
the Specialties Taking a
Toll The short list includes
cardiology, critical care,
diagnostic radiology, oncology,
and orthopedic surgery.
Shortages in dermatology,
general surgery, neurology,
psychiatry, urology, and
vascular surgery
Telemedicine: it’s more than technology
Current TeleICU Deployment
Current Statistics
• > 600 beds
• 26 facilities
• 47 units
• 5 tele-intensivists + 2 AC-
NP’s / night
• 1 tele-intensivist / day
• ~ 12 CC RN’s ATC
• 3-4 unit secretaries ATC
•Clinical Consensus Group governance
•Educational materials to patients/ families
•2 way audio/ video in monitored rooms
•Arranged visits to tele-ICU operations center for bedside nurses
Culture
•Managed by alternate, available in-house providers or newly trained
non-physician teams
Procedures
•All monitored rooms equipped with high-definition, tele-intensivist
controlled cameras
•Ability to view all vital signs data from all rooms in real-time
•RT performed, tele-intensivist interpreted real-time limited cardiac US
Physical Exam
•Funded by all receiving facilities with expectation of cost avoidance
savings from LOS reduction
Financing
Keys to Success
TeleICU – The foundation
297,613
fewer ICU days than predicted
550,916
fewer hospital days
2006-2018 Impact:
15,297 lives
estimated saved, as reported
(comparing to benchmark data)
Additional Telemedicine Programs
• Behavioral Health
– ED
– Integrated to PCP offices
• Stroke
• Specialty Consults
– Inpatient
– Clinic to clinic
• Direct-to-consumer virtual PCP
The Evolution of the Sepsis /
SaFE Alert
Origins within Banner
• Sparked by the 100,000 Lives Campaign and Surviving Sepsis
• Developed in 2010-2011, after a trial of 6 months, work was
continued in 2012 part of the CIPI Strategic Initiative
– Comprised of 3 components
• Severe Sepsis/ Septic Shock expected clinical practice
• A real-time, automated EMR-based screening system with alert
notifications
• Care sets optimized in alignment with the CP
– 2012 Metrics included:
• Outcome measure—severe sepsis house-wide mortality
• Process Measure—sepsis bundle compliance
• Context Measure—failure investigation
The Clinical Practice
• Contained requirements for
sepsis “resuscitation” and
“management” bundles
• Timelines defined for each
clinical care expectation
• Has been revised over the years,
based upon changes in our local
experience and the sepsis
literature
Automated, Real-Time EMR Surveillance
Timeframes were critical to ensure
the timely capture of a clinically
significant change
• 2 SIRS criteria must be met within 6
hours*
• 1 acute, organ system dysfunction
• Each SIRS and OD were independent
events, if each occurred within 8 hours
of the other, an alert was triggered, and
this time was used as “T-zero” for
calculating bundle compliance
Sepsis/ Shock Logic
Revised second ½ 2012
Placing in the Preliminary Sepsis Denominator
1. + sepsis alert per EMR surveillance
a. Inpatient based on listed triggers
b. ED based on same triggers + ED statement of
“Definitely/ Potentially” infected at time of
inpatient status placement
2. Use of sepsis care set
* exclusion of patient with DNR/ comfort care [cs] prior to or
within 6.75 hours of alert
Different Workflows were Developed Based on Patient’s Location
Inpatient
ED
Onscreen Alert Facilitated the Expected Management
RN Provider Notification
Care Set Inclusion Notifications
Missing Bundle
Elements
Elevated Lactic Acid Notification
Customized Care Sets Deployed
Locking the Denominator (early 2012)
• Determined by physician attestation at discharge
*If no response by 7 days after discharge, patient was defaulted into
sepsis denominator
…Late 2012
• Attestation now appeared 24 hours after alert firing
o If “yes,” patient locked in denominator
o If “no,” patient was removed from denominator and screening would resume
24 hours after attestation
o Failure to respond to form by 7 days post discharge would still lock patient in
denominator
“Just Culture” Failure Review Process
1
st
Year Results from Representative Facility
Outcome- Sepsis Mortality*
Sepsis Process—Bundle
Compliance
Sepsis Context—Just Culture
Investigation
End of Story???
True measure of “industry leadership” is not
in achieving a transient metrical success,
regardless of how profound, but in the
development and cultivation of those
institutions which permit continued progress.
Subsequent Changes
Since the end of the 2012 Strategic Initiative period:
– Change from denominator determination by physician attestation to
post-discharge coding per Angus Criteria
– Changes in advanced bundle elements, permitting POC cardiac US
assessment of volume status or CVP transduction
– Removal of requirement for ScvO2 measurement
– Changes in volume resuscitative approach
– Temporary alert suppression based on care set usage for patient
frequently triggering “false alerts”
– Automation of lactic acid measurement on alert triggering
Custom MPage Deployed in Late 2012
• Sortable by:
• Facility and/
or unit
• ED/ Inpatient
• 6 hours or 72
hours
• Displayed:
• Triggers
• Bundle
timeline
• Nursing
notification
• Pre/ post
alert lactate
• Blood cx*
• Antibiotics*
Renamed from “Sepsis alert” to “SAFE alert”
(Sepsis And perFusion Evaluation) in June 2014
– Done after above analysis revealed the
mortality of those that triggered the alert to
be ~ 30x higher than those that never
triggered it (5.2-5.8% vs 0.2%), with the mean
time from alert to death being ~ 5.3 days
– Mortality extended to those who were not
identified nor coded for severe sepsis
– Rebranding was intended to encourage a
broader diagnostic consideration than simply
sepsis in triggering patients, so that “mitigable
causes” of morbidity/ mortality could be
limited
Renaming the Alert
Centralized 2
nd
Look for Selected Patients
• Pilot was conducted in June 2012 at 3 facilities with teleICU
intensivists reviewing all sepsis alert and intervening in concert with
bedside as deemed necessary
• Later pilot was expanded to ~ ½ of patient population in June 2014
– Preliminary analysis reveals an improvement in “bundle compliance” with this
approach vs. solely bedside response
• Systemwide implementation occurred in October 2015, under the
following guidelines:
– Central review of patients with SAFE alert and automated lactate retuning >
2.0
– Bedside providers continue to receive the alert at the time of firing
Bundle Compliance Data Centralized Response
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
PreCentralized Review Centralized Review
Bundle Compliance/ Non-ICU in Applicable Facilities
Bundle Complaince/ Non-ICU Applicable Facilities
Linear (Bundle Complaince/ Non-ICU Applicable Facilities)
~ 32% increase
Dec2013-Jun2014
Jun2014-Oct2015
Recent Data with New Denominator
May-18
0.00%
50.00%
1
2
3
4
5
6
7
8
9
10
11
12
Representative Bundle
Compliance
May-18
0
0.2
1
2
3
4
5
6
7
8
9
10
11
Representative Sepsis
Mortality
Ongoing work…
• Sepsis is a Banner Strategic Initiative for 2019
• Clinical practice review and revision
• Re-evaluation of [cs]/[pp]-based alert suppressions
• Development of targeted [pp]’s for those non-sepsis clinical
entities found to frequently trigger SAFE alerts
